HomeMy WebLinkAbout1380 Calves Neck RdDate: 02/22/05
Town Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Receipt#:
4561
Transaction(s):
1 1
Permits
Reference
370
Subtotal
$170.00
Check#: 4561
Total Paid:
$170.00
Name:
Keyspan, Energy - Gas Cont Dept
175 E Old County Rd
Hicksvilie, NY 11801
Clerk ID: LINDAC Internal ID: 370
File No.
TOWN OF SOUTHOLD
HIGHWAY DEPARTMENT
Peconic Lane
Peconic, New York 11958
(631) 765-3140
APPLICATION/PERMIT FOR HIGHWAY EXCAVATION AND REPAIR
Re£#T100463837
APPLICATION IS HEREBY made to the Superintendent of Highways of the Town of Southold for the issuance of
an Excavation Permit pursuant to Chapter 83 of the Code of the Town of Southold, Suffolk County, New York, and other
applicable laws, ordinances or regulations for the excavation herein described. The applicant agrees to comply with all
applicable laws, ordinances, codes and regulations, and to permit authorized inspectors to make necessary inspections of the
job site.
Print or Type
1) KEYSPAN ENERGY - GAS CONSTR. DEPT. - 175 E. OLD COUNTRY RD. - HICKSVILLE. NY 11801
Name of Applicant Address
2) 1380 Calves Neck Road, Southold
Name of Owner of Premises
Addr~s
Calves Neck Road - bellhole w/s Calves Neck Road~ 65' n/o Harper Road~ Southold~ to install gas
service to house #1380
4) Work Description and Location (Street Number, Hamlet, Cross Street)
(a) ls construction located within 75 feet of tidal wetlands? *Yes
*If yes, other Town permits may be required.
No X
4) Builder's License No.
Electrician's License No.
s)
~igna~l~e of Al~licat~/
02-08-05
Date
a) Attach plot plan showing location of proposed excavation and relationship to adjoining premises or
public streets or areas, and giving a detailed description of layout of excavation.
b) Attach all other necessary permits and licenses for this project.
c) Work covered by this application may not commence before issuance ora Highway Excavation Permit
by the Town Clerk.
6) Tax Map: Section , Block , Lot
7) Starting Date: Completion Date:
8) Work Schedule:
Phase
Excavation .........................................................................
Facility Installation ...............................................................
Backfill & Compaction .........................................................
Pavement Replacement .........................................................
Completion Date
9) Under which authority is the application made:
10) Estimated Cost of Proposed Work: $
11) Remarks:
D=~9 Pa~e I of 3
T100463837
12) Insurance Coverage: (Attach Copy)
a) Insurance Company:
b) Policy #
c) State whether policy of certification on file with the Highway Department:
d) Coverage required extended to the Town:
Bodily injury and property damage: $300,000/$500,000 Bodily Injury, and $50,000 property damage.
13) Security:
a)
Surety Bond or Certified Check provided in the total amount
of $
b) Maintenance Bonded provided: 2 years or 3 years
14) Fees for applications and permits: Basic Application Fee
Al. I /Service Connections excavations ~ $20.00 = $20.00
$150.00
A2. /Additional Excavations same service ~ $10.00 =
No.
B. Excavations 18" in depth or less:
0-100 1.f. = $10.00 -
l.f. ~ $0.10
Additional
Excavations 18" in depth to 5' in depth:
0-100 1.f. =
Additional lf. @ .30 =
D. Excavations 5' in depth and over:
0-100 l.fi = $50.00
1.f. @ $0.50 = $
Additional
No.
Additional
Utility Repair Excavations ~ $10.00 = $
Repairs same service ~ $5.00 = $
Notice to public utilities proof must be provided and attached to this application prior to issuance of
permit.
TOTAL COST -- $170.00
Authorization is hereby gl'anted to the Town Clerk of the Town of Southold to issue a Highway Excavation Permit to:
KEYSPAN ENERGY DELIVERY in accordance with this application.
SUPERINTENDENT OF HIGHW,~,YS
TOW~'~_OUTHOLD, NEW/f~ORK
Recalv~ by the Tom Clerk
Date
Pe~t Issued ~/d 2~D ~ Pe~it No.
Not~: P~it expires one {1 ) year from Date of Issuance. No work to sta~ without 48 hour notice to the Superintendent of Highways.
P~it must be available for inspection.
D-39 Page 2 of 3
Copy Distribution:
Highway Department
Inspector
Applicant
Town Clerk
INSPECTOR'S RECORD
Inspection Date
1st
2nd
3rd
4th
Findings (use code)
Applicant Notified
(To Permit Clerk)
REMARKS
CODE
IB - Improper barricades
IL - Improper lights
ST - Sunken trench or excavation
UTM - Unable to measure (due to backfilling)
BUC - Building under Consiruction
WlP - Workin Progress
DB -lmpmper backfill (too high) (not sufficient)
HFS- Inspector holding for final settlement ofexcavation
RFR- Ready to Repair
D-39 Page 3 of 3
PERMIT APPLICATION SKETCH
DATE:
LOCATION:
TOWN:
WORK ORDER:
2~2005 2:02:02 PM
1380 CALVES NECK RD
SOUTHOLD
T1004631B7
VILLAGE OF
CROSS ~I]~EET: Hk~PER RD
SUP. FACE:
Iv',.ac aclara P~,ad
I~u,e N(~
1~0
C/~LVES NECK RD